Factors influencing intraoperative conversion from double- to single-incision mastectomy with free nipple grafts in 352 transgender and non-binary patients.

BACKGROUND: Double-incision mastectomy (DIM) with free nipple grafts (FNG) is a common technique employed in gender-affirming mastectomy (GAM), but is associated with a high scar burden. Intraoperatively, the surgeon may opt for a single-incision mastectomy (SIM) along the inframammary folds (IMF) to optimize aesthetic outcomes. This study sought to identify factors predictive of intraoperative conversion. METHODS: From February 2018 to November 2022, TGNB patients who underwent GAM at a single institution were retrospectively reviewed. Data regarding patient characteristics, perioperative details, postoperative complications, and aesthetic satisfaction were collected. RESULTS: A total of 352 patients were identified. Median age and body mass index (BMI) were 25.0 years (IQR: 9.0) and 28.5 kg/m2 (IQR: 8.5), respectively. Most patients received IMF incisions (n = 331, 94.0%); of whom, 66 (19.9%) underwent intraoperative conversion from DIM to SIM with FNG. Larger breast cup-size (p < 0.001) and a greater degree of ptosis (p = 0.002) preoperatively were significantly associated with intraoperative conversion to SIM. There was no significant association between intraoperative conversion and the ratio of intermammary distance to the width of the chest wall (p = 0.086). Overall complication rates were significantly higher among patients with diabetes mellitus (p = 0.015) and a greater degree of ptosis (p = 0.018). 77.8% (n = 274) of patients were satisfied with their aesthetic outcome. NPWT usage was associated with higher rates of aesthetic satisfaction (83.6% vs. 77.8%; p = 0.005). CONCLUSION: Patients with larger breast cup size and greater degree of ptosis should be counseled preoperatively that they may be at a higher risk of conversion to a singular incision.

Arterialized Vein Bypass Graft Recipient Vessel in Free Tissue Transfer Covering Diabetic Foot Ulcers Complicated by Critical Limb Ischemia.

ABSTRACT: Limb salvage options are limited in diabetic patients with critical limb ischemia. Soft tissue coverage remains technically demanding with limited recipient vessels for free tissue transfer. These factors make revascularization alone challenging. When open bypass revascularization is possible, venous bypass graft is optimal and functions as a recipient vessel for staged free tissue transfer.The authors present 2 cases using a combination approach of staged venous bypass graft revascularization followed by free tissue transfer with anastomosis to the venous bypass graft resulting in successful limb preservation.Free tissue transfer to a native vessel has limited application in severe peripheral vascular disease patients because early vascular compromise threatens flap survival. In both presented cases, venous bypass graft alone was insufficient to treat their nonhealing wounds, and preoperative angiogram revealed dismal options for free tissue transfer reconstruction. However, previous venous bypass graft provided an operable vessel for free tissue transfer anastomosis. The combination of venous bypass graft and free tissue transfer proved to be ideal for successful limb preservation by providing vascularized tissue to previously ischemic angiosomes, ensuring optimal wound healing capacity. Venous bypass graft is advantageous to native arterial grafts, and its combination with free tissue transfer likely increases graft patency and flap survival. We demonstrate that end-to-side anastomosis to a venous bypass graft is a viable option in these highly comorbid patients with favorable flap outcomes.

Trends in Fellowship Training across United States Plastic and Reconstructive Surgery Academic Faculty.

Plastic and reconstructive surgery (PRS) academic positions are more coveted each year. We aim to determine the requirement of fellowship training before PRS academic appointments. Methods: PRS faculty at U.S. academic institutions associated with the American Society of Plastic Surgeons were identified. Outcomes studied included integrated versus independent training, fellowships, gender, academic title, years on faculty, and publications before current hire. Results: Of the 1052 PRS faculty identified, 646 were included across 41 states and the District of Columbia. Seventy-four percent were identified as men (n = 477), and 26.2% (n = 169) identified as women. Academic faculty were significantly more likely to have completed fellowship before hire than not (p<0.0001). An integrated route of training was associated with higher odds of fellowship completion before appointment (OR = 2.19, 95% CI: 1.49-3.22). Odds of fellowship completion was significantly greater among faculty who graduated 5-10 years ago (OR = 2.55, 95% CI: 1.48-4.41) and within the last 5 years (OR = 1.93, 95% CI: 1.18-3.17). Professors were less likely to have completed fellowship training before appointment compared with assistant professors (OR = 0.51, 95% CI: 0.33-0.80). Regarding gender, number of prior publications, or completion of another degree, no significant difference was found between fellowship- and non-fellowship-trained faculty. Conclusions: Although more plastic surgeons enter the field through a shortened integrated residency, the increasing demand for further subspecialization may cause significant challenges for upcoming graduates pursuing an academic appointment. Undergoing additional training considerably impacts social and financial decision-making early in surgical careers for newly graduated residents.

Incorporating the Osseous Genioplasty Into Rejuvenation of the Lower Face.

BACKGROUND: The chin plays a critical role in the shape, projection, and soft tissue support of the lower face. Osseous genioplasty is a powerful tool in facial rejuvenation as it allows for optimal control of the resulting chin dimensions and improvement in submental and submandibular laxity. Osseous genioplasty can be used alone or in combination with other facial rejuvenation procedures to achieve an optimal result. OBJECTIVES: The aim of this study was to present the senior author's approach to skeletal analysis of the lower facial third and propose an algorithm that can be used to optimize skeletal support of the overlying soft tissue laxity while maintaining an aesthetic facial shape and proportion of the chin. METHODS: All patients undergoing cosmetic osseous genioplasty for soft tissue rejuvenation of the lower face and/or perioral region with the senior author between 2010 and 2021 were retrospectively reviewed. Complications, including infection, numbness, and prolonged ecchymosis, were recorded. RESULTS: A total of 37 patients underwent cosmetic osseous genioplasty. The average age of the cohort was 44.5 years. Twenty-six patients (70.3%) were female. Eleven patients (29.7%) underwent genioplasty alone. In addition to genioplasty, 8 patients (21.6%) underwent orthognathic surgery, 5 patients (13.5%) underwent platysmaplasty and liposuction, and 2 patients (5.4%) underwent facelift. The authors propose an algorithm to guide evaluation of the lower facial third to help determine the possible role of osseous genioplasty for facial rejuvenation based on each patient's unique facial characteristics. CONCLUSIONS: In properly selected patients, osseous genioplasty can improve lower facial projection, submandibular laxity, and perioral soft tissue support while also optimizing facial shape and proportion.

Increasing Fat Graft Retention in Irradiated Tissue after Preconditioning with External Volume Expansion.

BACKGROUND: Fat grafting is an adjuvant that may improve the quality of radiation-damaged tissue. However, fat grafting for volume restoration in irradiated sites may be less effective because of a poorly vascularized fibrotic recipient bed. External volume expansion has emerged as a potential technique to prepare the recipient sites for improved survival of grafted fat. The authors previously demonstrated increased vasculature with external volume expansion stimulation of irradiated tissues. The authors now hypothesize that external volume expansion's improvements in recipient-site vascularity will increase the volume retention and quality of fat grafts in fibrotic irradiated sites. METHODS: Athymic mice were irradiated until development of chronic radiation injury. Then, the irradiated site was stimulated by external volume expansion (external volume expansion group), followed by subcutaneous fat grafting. Grafts in an irradiated site without external volume expansion stimulation (irradiated control group) and grafts in a healthy nonirradiated (nonirradiated control group) site were used as controls. All grafts were monitored for 8 weeks and evaluated both histologically and by micro-computed tomography for analysis of volume retention. RESULTS: Hyperspectral imaging confirmed a 25 percent decrease in vascularity of irradiated tissue (irradiated control group) compared with nonirradiated tissue (nonirradiated control group). Grafts in the irradiated control group retained 11 percent less volume than grafts in the nonirradiated control group. The experimental external volume expansion group achieved a 20 percent (p = 0.01) increase in retained graft volume compared with the irradiated control group. CONCLUSIONS: External volume expansion stimulation can mitigate the effects of irradiation at the recipient site and in turn help preserve fat graft volume retention. Possible mechanisms include increased vascularity, adipogenic conversion, and increased compliance of a fibrotic recipient site.